Mutual of Omaha uses this two-page statement with a policyowner's individual disability income claim. The treating physician covers history (onset, date work ceased, prior similar conditions, work relation, pregnancy), primary and secondary diagnoses, symptoms and objective findings, treatment dates and nature, and the extent of disability, including when the patient may return to some or all duties.
The attending physician completes the whole statement and signs with degree and TIN. The policyowner completes the separate First Policy Owner Disability Claim Form (M20740).
Download the current version from the source each time; forms change without notice.
Attending Physician's Statement
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Yes. Mutual of Omaha's forms finder lists a Spanish Attending Physicians Statement alongside the English M20722 under its individual disability claim forms. Both go with the policyowner's disability claim and carry the claim and policy numbers at the top.
Item 2F asks whether the physician has completed claim forms for other insurance carriers and, if so, which company. Item 2E asks whether the physician has treated the patient for any other conditions, and item 2G asks for other treating physicians or consultants.